Perceptions of Saskatchewan Community Pharmacists Regarding a Prior-Authorization Program

BACKGROUND: In 1999, Saskatchewan Health authorized pharmacists to initiate exception drug status (EdS) requests, also known as prior authorization (Pa). Before 1999, only those licensed to prescribe medications were authorized to initiate EdS requests. A pharmacist who submits an EdS request must obtain a patient diagnosis from the physician or agent of the physician; a diagnosis presented by the patient is insufficient. OBJECTIVES: to obtain pharmacists' opinions about the benefits of the Pa program of the Saskatchewan drug Plan and to identify factors associated with pharmacist-initiated EdS requests. METHODS: a census survey of community pharmacy managers was conducted via a self-administered postal questionnaire in the province of Saskatchewan, Canada, in the fall of 2004. The survey questionnaire was addressed to pharmacy managers, some of whom may have delegated the response to a staff pharmacist. Pharmacy managers or their delegates were asked to respond on behalf of all pharmacists in their pharmacies. RESULTS: a response rate of 82.6% was achieved (275/333). A majority of respondents agreed that the province's Pa program (EdS) benefited patients (87.3%) and the Saskatchewan drug Plan (82.5%), whereas only 33.4% of respondents agreed that the EdS program benefited pharmacists. Pharmacists' ability to obtain the requisite information (87.6%) and to contact the prescribing physician (87.3%), as well as patient-centered concerns such as the patient's ability to pay for the prescription (85.1%), were the most important factors. the time required by the pharmacist to initiate the request was not important relative to other factors. Community pharmacies reported receipt of an average of 36.4 prescriptions for restricted and nonformulary drugs per week, of which 22 were submitted for Pa coverage, 17 by the pharmacy and 5 by the pharmacy at the request of the physician. CONCLUSIONS: the results of this study indicate that community pharmacists in Saskatchewan acknowledge that the EdS process is beneficial for their patients. However, pharmacists are burdened by an administrative process in which necessary information, particularly the patient diagnosis, is not readily available.


Survey Instrument
Drawing on ar eviewo ft he relevant literature, 6,22-44 we constructed theq uestionnairet oa ddress as erieso ft opicsr elating to PA andthe EDSp rogram in Saskatchewan. These topic areas included potentials takeholder benefits from aP Ap rogram,t he volume of EDSrequestsreceivedbythe pharmacy,factors influencing thedecisiontoinitiatearequest,and theappropriateness of procedures used to submit ar equest.I nformation wasa lso gathered with regard to thearea, location, andtypeofpharmacy; then umbero fp harmacists andp harmacyt echniciansi nt he respondent's pharmacy;t he proximityo ft he prescribingp hysicians; prescription volume;and hoursthe dispensary waso pen. Demographics were also collected on respondents'g ender, age, position,and yearsintheir currentposition.
With regard to the1 999 policy change allowingpharmacists to initiate EDSr equests, 71%a greedo rs tronglya greedthatthe change in policy hadb een beneficial to patientc are. However, most (96%)a greedt hatt he change hads ignificantly increased
Givent he additional workloadd emands thatt he EDSp rogram places on pharmacists, it wasn ot unexpected thatt he respondents believed thatp harmacists benefited thel east from theE DS program. However, it wass omewhat surprising that pharmacistsr eported thatt he time required to providet he service wasthe leasti mportant factor when deciding to initiate an EDSr equest.F actors such as thea bility to obtain ther equired information andt he ability to contactt he prescriberw ereo f greaterconcern.Thissuggestsaneedtoimprove communication andt he role definition forb otht he pharmacist andt he physician.Effective communicationand collaborationbetween physiciansa nd pharmacistsw ill likelyi mprove humanistic-service outcomes forp atients, includingr eduction in thetimed elaysin obtainingmedications. 18 Respondentsi nt he samel ocationa sp rescribing physicians werel esslikelyt obeconcernedwiththeir ability to contact the physician.C o-locationsa nd greatero pportunity forf ace-to-face interactiona llowst he pharmacist(s)t oe stablish good working relationshipsw ithp rescribers.G ood workingr elationships,i n turn,w ould be expected to supportg reater accessibility when initiatinganEDS request.
The ability of thep atient to payw as also ak ey factor in pharmacist decisionst os ubmit requests forE DS coverage. If a patientisunabletopay thecost sharefor themedication, even if approvedvia EDS, it is notproductivefor thepharmacisttoapply forEDS coverage. Although it appears thatr espondentsd on ot necessarily mindt he time required to submit an EDSr equest, they are concernedabout theirability to obtain theinformation necessary forinitiatinganE DS request. The fact thatp harmacists aren ot likely to have thei nformation required fora nE DS requesti st roubling.T he idea behinda uthorizingp harmacistst oa pplyf or EDSo nb ehalfo fp atientsw as to increase timely access to prescription drugsf or patients.H owever, whent he pharmacist does noth avet he necessaryi nforma-tion to make thatrequest in atimelymanner,the processmay actually be lengthened. 36 An evolving partialsolutionmay be foundinthe Saskatchewan Pharmaceutical InformationProgram (PIP). PIPisdesignedtolink communityp hysicians, pharmacies,and hospitals, providingconfidentials hareda ccesst op atient medicationh istories. 46 However, whileP IP mayh elpalleviate some of thecurrentbarrierst op harmacist review of thec ompletem edicationh istory forap atient,i t does notprovide thepharmacistwithaccesstoother medicalinfor-  In July 2006,t he Saskatchewan Drug Plan implemented 2changes to help streamline theEDS applicationprocess.First, indefinitea pprovalw as permitted for1 16 drugso r4 42 EDS drug information numbers( DINs), analogoust oN ationalD rug Code (NDC)n umbers in theU nited States.S econd,o nline adjudication wasi mplemented for2d rugs,p ioglitazoneH Cl andr osiglitazone maleate. EDSc laimsf or thesea gentsc an be submitted anda djudicated directly throught he online claims transactionalp rocessings ystem, whiche mploys a" smarte dit" to searchf or evidence of prior use of first-line therapyo rp rior useo ft he target drug thatw ould have been associated with an EDSa pproval. 15 Whilet hisi sap ositives tepi na ddressing some of theissuesaroundthe administrative workloadinherent in PA programs,t he online adjudication system currentlyo nly includes 2drugs.

Limitations
First, this is ap reliminarys tudy of pharmacist perceptions thatd id noti nvolve collectingi nformation thatm ight be used to improvep rocesses such as thea veraget imer equiredo f pharmacy staffper EDSsubmission andthe proportion of total pharmacy time andp ayroll consumed by theE DS process. Second,the resultsobtainedfromthe survey pertainonlytothe province of Saskatchewan,C anada, andm ay notb ea pplicable to otherjurisdictions.Third,since this survey wasaddressed to communityp harmacymanagers, ther espondentst endedt ob e oldera nd were oftent he ownerso ft he pharmacies.T herefore, theo pinionsrecordedinthissurveymay notrepresent practicingpharmacists in general.

Conclusions
Pharmacistsrespondingtothe survey viewed theEDS programas beingbeneficial to patients butw erec oncerned with thea dministrativeb urden. Concerns with theE DS programf ocus on the administrative nature of thep rogram,i ncluding thei nefficient manner in whichp harmacists arer equired to applyf or EDS duet ol acko fa ccess to required patienti nformation,i ncluding diagnosisa nd complete prescription drug history. To maintain pharmacists' supportf or this managedc arei ntervention,i tw ill be necessaryt or educet he administrative workload by providingaccess to required information andimplementingsmart edits thats can pharmac yc laimsh istory f or evidence of pr ioru se of first-line drug therapy. Furtherresearchisneededt ocapture the perceptionsa nd experienceso fa ll stakeholders of theE DS program,includingpharmacists,physicians, patients,and drug plan personnel, to help assess humanistic-service outcomes of this managedcareintervention.